Strategies for Safer Care: Where are We Going with Patient & Family Engagement?

Transcription

1 Strategies for Safer Care: Where are We Going with Patient & Family Engagement? Illinois Association for Healthcare Quality April 29, 2016 Itasca, IL Martin J Hatlie, JD, CEO Project Patient Care

2 Learning Objectives 1. Describe how patients and families partnered with providers of care to improve outcomes during the federal Partnership for Patients campaign, which concluded in 2014 and saved at least 50,000 patient lives. 2. Recognize and explore opportunities for engaging patients in improvement work that participants can be in action on now.

3 Themes today Expanding support for PFE by the U.S. Govt: What is shaping the future? PFE as an performance strategy (Outcomes & Value) PFE infrastructure PFE and health equity PFE Worker safety and joy & meaning in work PFE metrics and incentives

4 Partnering with Patients & Families An Opportunity to Make Incredible Change

5 Rx For The Blockbuster Drug Of Patient Engagement, Health Affairs 32(2), 202 (2013) Even in an age of hype, calling something the blockbuster drug of the century grabs our attention. In this case, the drug is actually a concept patient activation and engagement that should have formed the heart of health care all along. Susan Dentzer, Editor Health Affairs

6 CMS PFE Embedded in CMS Quality Strategy Better Care Healthier People Foundational Principles Enable Innovation Foster learning organizations Eliminate disparities Strengthen infrastructure and data systems Smarter Spending Goals Make care safer Strengthen person and family centered care Promote effective communications and care coordination Promote effective prevention and treatment Promote best practices for healthy living Make care affordable 6

7 PFE Environmental Scan Partnership from Patients (PfP) Campaigns 1.0, 2.0 Frameworks/Roadmaps Metrics Alignment of PFE with outcomes improvement work CMS overall PFE strategy, announced at 2015 Quality Conference Signaled the shift from patient to person AHRQ Toolkits Seven Pillars Program CANDOR = Communication and Optimal Resolution Guide to Patient and Family Engagement in Primary Care New Quality Improvement Organization (QIN-QIO) Campaign on Medication Self-Management Transforming Clinical Practice Initiative (TCPI) 7

8 Partnership for Patients (PFP) Campaign Launched in April 2011, ended on 12/31/14 Coordinated by CMS Innovations Center Safety Goals: 40% reduction in Hospital Acquired Events 20% reduction in readmissions Projected Outcomes: 60,000 lives saved, 1.8 million fewer injuries 1.6 million people recover without readmission $35 billion saved ($10 billion to Medicare) Now in Phase 2.0, with 3.0 predicted if Goals are met by 12/31/16

9 Partnership for Patients CMS Innovation Center Key Components $500 million in funding via Affordable Care Act Hospital Engagement Networks (HEN) 26 + American Hospital Association (32) Disseminate to networks of 50+ hospitals Coach and support Track and monitor Federal Contractors report to CMS Up and out spread of innovation

10 PfP Areas of Focus 1. Adverse drug events (ADE) 2. Catheter-associated urinary tract infections (CAUTI) 3. Central line-associated blood stream infections (CLABSI) 4. Injuries from falls and immobility 5. Obstetrical adverse events 6. Pressure ulcers 7. Surgical site infections 8. Venous thromboembolism (VTE) 9. Ventilator-associated pneumonia (VAP) 10. Preventable readmissions

11 Leading Edge Advanced Practice Topics (LEAPT) 1. Severe Sepsis and Septic Shock 2. Clostridium Difficile 3. Hospital-Acquired Acute Renal Failure 4. Airway Safety 5. Iatrogenic Delirium 6. Procedural Harm 7. Undue Exposure to Radiation 8. Failure to Rescue 9. Results Beyond the 40/20 Aims on HACs and readmissions 10. Hospital Culture of Safety Including Worker Safety 11. Cost Savings Calculations for HACs

12 Partnership for Patients 3 Campaign Engines

13 Patient and Family Engagement (PFE) 2011 Baseline & Campaign Focus Baseline: PFE as an end in itself, shaped by policy Ethics (First Do No Harm) Human Rights & Principles of Patient Centered Care Crossing the Quality Chasm aims for transformation in the 21 st Century Baseline: Most PFE work focused on improving the patient experience, usually as measured by HCAHPS Campaign focus: PFE as a strategy for improving outcomes, Safety/Harm Across the Board (S/HAB) & Culture of leadership/safety/transparency

14 PFP Promoting Engagement with Patients & Leaders (PEPL) Metrics Hospital Leadership On PFP Goals Hospital Structure For Patient Family Engagement Governance Policy and Protocol Public Commitment to PFP Safety, Data Transparency Board Quality Committee Reviews Safety Data Regular Quality Review Aligned with PFP goals Patient Family Engagement (PFE) Advocate on The Board Active PFE Committee or Advocate Staff w Proactive PFE Responsibility PFE Advocates Are SAB Trained Point of Care Staff Have Explicit Role in Patient Safety Pre-Admission Checklist w Patient Huddles With Patient, Family Post-Discharge Medication Reconciliation w Patient/Family

15 Percentage of Hospitals Meeting Each PFE Metric, July 2013 and November 2014

16 PFE and Leadership Metrics Correlation PFE Metrics Not All Leadership Metrics Met (N=1,172) All Leadership Metrics Met (N=2,567) Percent hospitals meeting at least one structural PFE metric (PFE 3, 4, or 5) 56% 85% Percent hospitals w/ leader assigned 39% 68% Percent hospitals w/ committee/representative 30% 59% Percent hospitals w/ representative on board 28% 54% Average number of PFE metrics met (Nov 14) Percent PFE opportunities met (data from Jul 13 - Nov 14) 27% 47% 16

17 Carolinas HealthCare Pattern PFE and Campaign Outcomes 17

18 Minnesota HEN Pattern PFE and Campaign Outcomes 1.1 Comparing Minnesota PPR of Low Performers (0-3 PFE) to High Performers (4-5 PFE) PPR ratio # PFE met 0-3 # PFE met 4-5

19 RARE: Reducing Avoidable Readmissions Effectively in Minnesota Results: 7,030 readmissions avoided (as of Q3 2013) Exceeded original goal of 6,000 readmissions Helped patients spend 24,844 more nights sleeping comfortably in their own beds Reduced inpatient costs by an estimated $55 million 2013 winner of the John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality

20 PFE Contributions to the PfP Campaign PFE as a provider/user partnership strategy Patient stories as motivators Patient and family contributions to learning/improvement PFE as a pull strategy to drive demand for improvement Patient advocate buzz about the PfP Campaign created excitement or change of opinion Outreach to patient advocacy groups reframed PFE as an improvement strategy Engagement of PFAC members in safety work is creating expectation of a new normal in U.S. healthcare system? PFE as a culture change strategy The conversation changes when the patient is in the room

21 National Partnership for Women & Families/American Institutes for Research Framework Karman KL et al, Health Affairs v. 32 no (2013) 21

22 HRET Framework 2 2

23 HIMSS Framework DetailPDF.aspx?ItemNumber=28305

24 Themes today: PFE infrastructure Patient-Centered Care focused Traditional PFACs Builds on lesson learned from hospitals in action since the 1990s Emphasis on principles of patient centered-care & patient experience Members typically patients / family members, supported by hospital staff Reporting relationships vary widely Safety, Outcomes & Partnership focused Evolving to PFPCQS Builds on foundational elements of PFACs; adds high reliability elements & quality improvement work Emphasis on outcomes Models partnership - both users & providers of care are council members Reports to Board of Directors or senior management Aligns with emerging research opportunities Aligns with developing federal measures 24

25 Vidant Health PFAC Structure Vidant Health: Organizational Structure for Patient Advisory Councils Vidant Medical Center Patient-Family Advisory Council Vidant Bertie Hospital Patient-Family Advisory Council Vidant Chowan Hospital Patient-Family Advisory Council Vidant Duplin Hospital Patient-Family Advisory Council Vidant Edgecombe Hospital Patient-Family Advisory Council Vidant Roanoke- Chowan Hospital Patient-Family Advisory Council Vidant Beaufort Hospital Patient-Family Advisory The Outer Banks Hospital Patient-Family Advisory Council Vidant Medical Center Service Line Patient-Family Advisory Councils Vidant Employee Health Patient-Family Advisory Council Vidant Home Health And Hospice Patient-Family Advisory Council Vidant Medical Group Patient-Family Advisory Councils Vidant SurgiCenter Patient-Family Advisory Council Future Councils will be more community based organized geographically 25

26 MedStar Health: HRO Roadmap 10-8 Optimized Outcomes Transparency Patient Human & Family Factors Partnerships Integration Including the Patient Voice in all we do Reliability Human Factors Integration Reliability Culture Intuitive design. Impossible to do the wrong thing. Obvious to do the right thing. Simulation/Innovation Core Values & Vertical Integration Hire for Fit Behavior Expectations for all Fair, Just and 200% Accountability Process Design Template credit to HPI Evidence-Based Best Practice Clinical Decision Support/IT Focus & Simplify Tactical Improvements (e.g. Bundles) 26

27 MedStar Health, Inc.: Organizational Structure for Council System PFACQS Reports to Board QSPAC Committee Reports to VP, Quality and Safety Meets quarterly; local PFACQS members invited Members may share their MedStar insights in national engagements Local PFACQS Report to entity Board Quality and Safety Report to system VP, Quality and Safety Report to System PFACQS Meet monthly at entity Meet bi-monthly as group Share projects, progress across MedStar and with community 27

28 Butler Health System PFPCQS Board of Directors Quality & Professional Affairs Committee Patient and Family Partnership Council for Quality and Safety Patient Safety Committee

29 Butler Health s PFPCQS First Year Output Changes made to the Patient Handbook Feedback given to marketing regarding the website appearance and social media responses Patient members volunteered to observe in the waiting room of the ER and provided feedback to the ER Director Quiet Protocol posters changes made based on suggestions Environmental Services changed current practices based on feedback Proposed a recognition program for staff patient and family vouchers to give to staff who provide exceptional service Previewed orthopedic patient engagement software and provided feedback during revision project Patient and family members being interviewed for employee mandatory in-service video Patient Expectation video reviewed and feedback given 2016 Strategic Plan: PFPCQS to develop two improvement projects 29

30 Eliminating Harm, Improving Patient Care: A Trustee Guide

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33 Patient & Family Engagement HRET Roadmap Joe Clothier, Patient Advocate Council and Member of the Quality Council It is impressive to me that Logansport Memorial Hospital is excited about including patient s input as a necessary component of their Quality Improvement Philosophy. Asking members of the community to be part of the Patient Advisory Committee, and having a Patient Advocate Council Member as a member of the Quality Council can, with time, open up needed dialogue between patients and LMH. I believe this is a huge step towards improving the level of care given to patients in the Logansport area.

34 Themes today: PFE as a Performance/ Outcomes Improvement Strategy Baptist Health South Florida Providence Everett evision/programs/2014/09/03/top-10-tips-forhospital-patient-safety/ /

35 Themes today: PFE and Health Equity WmBo

36 Equity as a Performance Strategy Treat the Whole Person Establish Patient and Family Engagement Infrastructure Add REAL (Race, Ethnicity and Language) Data to Clinical Integration Model Reporting Identify Performance Gaps Build Formal Platforms to Support Transparency and Sharing Build Quality Improvement Initiatives Targeting the Gaps Improve Discharge Planning Improve Care Coordination Increase Availability of Culturally and Linguistically Appropriate Services (CLAS) Create Strategic Partnerships with Community

37 Addressing Disparities Baumann, L. C., & Dang, T. T. (2012). Helping patients with chronic conditions overcome barriers to self-care. The Nurse Practitioner, 37(3), 32-38http:// Barriers to self-management of chronic conditions can be placed into the following categories: 1. Physical 2. Psychological 3. Cognitive 4. Economic 5. Social 6. Cultural Strategies Used by Providers to Achieve Ability To Self-Care: Motivational interviewing Assessing cultural beliefs Enhancing self-efficacy Peer support

38 Chronic Care Model Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A Survey of Leading Chronic Disease Management Programs: Are They Consistent with the Literature? Managed Care Quarterly. 1999;7(3):56 66.

39 The TCPI Change Package Structure Expanded driver diagram Practice aims aligned with TCPI goals Change Tactics Broad concepts that prompt specific change ideas derived from site visits/ high performers 39

40 TCPI Drivers: Essential factors to achieve the aims TCPI AIMs/Goals 1) Practice Transformation. Evidence of a culture of quality where the vision is clear and data is used to drive continuous improvement in quality, outcomes, cost of care and patient, family and staff experience. 2) Effective solutions moving to scale. Evidence of practice spreading effective improvement strategies to full scale for the entire population under its care 3) High Clinical Effectiveness: Practice is effective in bringing all patient segments to their health status goals. 4) Reduced Avoidable Hospital Use: Rates of readmission and unnecessary admissions for practice s patients have been reduced. 5) Reduced Unnecessary Testing & Procedures: Practice demonstrates a reduction in unnecessary testing and in the use of the ED by its patient population. 6) Reduced costs: Practice controls its internal costs as well as other elements of total cost of care. 7) Documented Value: Practice can articulate its value proposition and increases participation in available valuebased payment agreements. Primary Drivers Patient and Family-Centered Care Design Continuous, Data-Driven Quality Improvement Sustainable Business Operations Secondary Drivers 1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner 1.5 Coordinated care delivery 1.6 Organized, evidence based care 1.7 Enhanced Access 2.1 Engaged and committed leadership 2.2 Quality improvement strategy supporting a culture of quality and safety 2.3 Transparent measurement and monitoring 2.4 Optimal use of HIT 3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation 40

41 AHRQ Guide to PFE in Primary Care Research Question What are effective and potentially generalizable approaches for engaging patients and families to improve patient safety in primary care settings? 41

42 Goals of the AHRQ Guide 1. Synthesize research in the field 2. Inventory and describe existing interventions 3. Qualitatively evaluate effectiveness and usability of interventions identified 4. Identify gaps in the field and areas ready for intervention development 5. Prepare case studies highlighting activities of 4 primary care practices 1. Develop and disseminate interventions

43 AHRQ Environmental Scan 1. Synthesize research in the field 2. Inventory and describe interventions 3. Qualitatively evaluate effectiveness and usability of interventions identified 4. Identify gaps in the field and areas ready for intervention development Patient & Family Engagement (PFE) Patient Safety Primary Care Settings

44 Four Key Threats to Patient Safety Breakdowns in communication Among patient, provider, practice staff Medication management Prescribing, filling, adherence, overuse Diagnosis and treatment Decision making, information transfer, missed diagnosis, delayed diagnosis Fragmentation and environment of care Care coordination, safety culture, reporting, error identification and management May 2,

45 AHRQ Environmental Scan Implications for the Guide PFE interventions focused primarily on the patient as the agent of change haven t been measurably successful Education alone is unsustainable yet it is the focus of most interventions Limited evidence of usability and adoption Health equity and literacy are cited as a concern, but not often a focus of interventions May 2,

46 AHRQ Guide: Recommended Interventions (= TCPI Tactics?) 1. Family engagement in care 2. Teach back 3. Warm hand-offs 4. Medication safety interventions Patient and family advisory councils Shared decision-making May 2,

47 QIN-QIO CAMPAIGN FOR MEDS MANAGEMENT (CMM)? 6 month pilot of the QIN-QIO program informed and driven by the experiences of medication users successfully managing their medication use. Will develop and test self-management methods for safe medication use in a number of beneficiary/provider communities Jun - Dec 2016 If successful self-management innovations will be spread in 2017

48 QIN-QIO Campaign for Meds Management (CMM) National Medication Safety Network formed to Continue Spread and Improvement of Medication Self- Management System A Two Phase Campaign Phase 1. (12 months) Develop and test successful patient medication selfmanagement programs by 1/1/17 using rapid cycle prototyping Phase 2. (18 months) Health coalitions in 50% of counties in US have adopted the evidencebased medication selfmanagement system by 12/18. Impact: CMS estimates increase in patient at goal, reduce care utilization, reduced total cost of care. Outcome: Health coalitions in 50% of counties adopt evidencebased medication selfmanagement system 48

49 Medication Self-Management for Patients & Family: A Stable and Effective 3-Dimensional Structure Patient and Family Situation Assessment & Community Support Community Pharmacist Home Health Social Services Physician & Office Staff Payer

50 Themes today: PFE metrics and incentives What should we measure? Specific harms prevented All cause harm? Cost to system? Broader costs -- Impact on families? Em E-patient engagement? Other outcomes

51 Themes today: PFE metrics and incentives Outcomes to Work On? Adverse Drug Events Catheter-Associated Urinary Tract Infections Central Line Associated Blood Stream Infections Injuries from Falls and Immobility Obstetrical Adverse Events Pressure Ulcers Surgical Site Infections Venous Thromboembolism Reducing Hospital Readmissions Clostridium Difficile (c-diff) Airway Safety Severe Sepsis and Septic Shock Hospital Acquired Acute Renal Failure Ventilator-Associated Pneumonia Effective Management of Critical Test Results Iatrogenic Delirium Procedural Harm Undue Exposure to Radiation Failure to Rescue Hospital Culture of Safety MRSA Pain management

52 Tom Evans, MD: Our Long Journey to Partnering with Patients Stage 1. Working without patient input Stage 2. Dropping the wall of silence Stage 3. Listening to patient stories Stage 4. Engaging patients in our work Stage 5. Partnering with patients Tom Evans, Iowa Healthcare Collaborative "for them but not with them inviting patients into the improvement work room using their stories to motivate and guide showing patients our improvement work, asking for feedback patients bring ideas up and providers listen; providers and users of care jointly make decisions, set priorities.